What is a skin graft?

A skin graft is the transfer of healthy skin from one part of the body to replace the burn wound. The skin graft must be taken from your own skin as skin donated from friends, family will be rejected by your body. 

The skin is a very important and provides a protective barrier to the organs in the body; it prevents infection and water loss. When the skin is damaged by a burn or scald the protection is lost. If the burn is deeper than the top layer of skin a skin graft may be required, the burns team will explain and discuss your surgical and wound management options. 

A skin graft is necessary when the cells needed to repair the skin have been lost or damaged and new cells are needed. This is due to the burn wound extending deeper into the skin dermal layers and cells that would normally heal the burn wound have been destroyed. Without a skin graft the risk of infection is high, you may incur a delayed wound healing time or the burn wound may not heal at all.

‘Image taken from EnchantedLearning.com with permission’ 

How is the skin graft taken?

This is a surgical procedure, which will require a general anaesthetic. The surgeon will take a thin shaving of healthy skin and put it on the cleaned burn wound. This new wound is called the ‘donor site’ and will have a dressing on it.

How does the skin graft stay in place?

The skin graft may be stapled, stitched or glued, depending on the size and depth of the graft and the site of the wound, most grafts are glued. The graft will then have a dressing over it for protection. These techniques depend on the patient, the size of the skin graft and the area where it is applied or on the consultant’s instructions. If the graft is on or near a joint, a splint may be used to reduce movement to protect the graft.

How long do these wounds take to heal?

The healing time will depend on the size and depth of the wound. The aim is to get the wound healed in about two weeks, but healing may take longer. Infection can slow down healing. Smoking can also affect healing. It is advisable to try to stop smoking.

Are there any risks?

The risks will be explained by the surgeon when they ask you to sign the consent form for the operation. The risks include bleeding (in some cases a blood transfusion may be required, this will be discussed with you) infection and partial or complete loss of graft. Re-grafting may be required if the wounds are over a large area or some or all the graft is lost.

Please ask your doctor or nurse if you would like further information about any of these points and poor nutrition.

What dressings will be used?

Both the donor site and skin grafts will be covered by dressings (unless they are on the face). The dressings might be different each time they are changed but this will be explained by your nurse. The type of dressings may also change as the wounds heal. Please ask the nurse if you have any questions about the dressings used.

When I can I start walking after a skin graft?

It can depend on where it is. If it is anywhere other than your leg(s), you can start walking as soon as you feel up to it. If it is on one or both of your legs, then we encourage you to stay on bed rest for several days or until the skin graft is secure enough for walking on. The nursing staff will advise you when you can start to walk. You may be referred to a physiotherapist to help with this.

What can help the wounds heal?

It is important that the care instructions given by the surgeons and nurses are followed, to give the graft a good chance of healing. A healthy balanced diet that includes plenty of protein is important. Protein foods include: milk, cheese, yoghurts, eggs, meat, fish. Smoking and passive smoking slows down the healing by reducing the amount of oxygen reaching the skin.

Will I need to keep it dressed when I go home?

Yes. In the early days a protective dressing will be necessary. This may be changed in our adult burns clinic and if you are unable to attend this will be changed by a district nurse or by your GP practice if you can attend there. You will have to return to the hospital for follow up appointments to see the doctors.

What will my grafted skin look like?

With any skin graft, scar formation is inevitable, but the appearance of your graft will change considerably over the weeks and months to follow, so its initial appearance should not cause alarm. This can be of a meshed netted pattern appearance or small fenestrated lines depending on the depth of skin graft taken from the donor site. It can take up to two years for a scar to ‘mature’, usually leaving a pale, soft and supple scar. 

Once the graft is healed you will be referred to the scar management team as you may be at risk of developing scarring. This can appear as raised, red, firm, itchy scarring which may develop for about three months after you have healed. The scar management service will closely monitor this and provide appropriate treatment if required.

Small areas of wound breakdown and blisters are common on the newly healed skin as it is thinner and more sensitive. This may occur due to irritation from clothing or accidental bumps and bruises. If this happens these can be protected with small dressings to prevent further damage and help healing.

How do I care for the skin graft once it is healed?

Skin grafts have fewer oil and sweat glands, so tend to become dry. When the graft can be left exposed and is completely healed, it should be kept clean by gently washing it as normal. Avoid very hot water and never use highly perfumed soaps, creams or bubble baths. After bathing gently pat the grafts dry and then massage the area with non-perfumed moisturising cream or simple emollients as least twice a day to keep the area supple. This is only usually kept up for six months. You will be given advice on this prior to discharge and by the scar management team.

Will I need to wear any support when I go home?

You may be advised to wear Tubigrip (an elastic stocking) as part of your rehabilitation plan by the scar management team.

Is there any other advice I should know about caring for my skin graft?

It is very important that both the skin graft and donor sites are protected from the sun as it is new thinner skin without the normal skin protection. It is very important that for the next two years/summers that you apply high factor sun protection (both form UVA and UVB) or use total sun block cream and wear sun protective clothing over these areas, as new skin will burn and blister very quickly.

Sun burn to graft and donor sites may worsen appearance of these areas. If it becomes tanned this can be a permanent tan that can be blotchy.

What is a donor site?

A donor site is the area left when a piece of skin graft has been taken to cover a defect on another part of the body. There are various parts from where the skin can be taken, such as the thigh, upper arm, or even the buttocks.

How long will it take for the donor site to heal?

It usually takes around ten to fourteen days. The dressing applied in theatre at the time of your operation will stay in place for that period and should be kept clean and dry. A donor site is like a bad graze, so the dressing protects the raw surface and allows it to heal. It also soaks up any fluid that naturally seeps from the wound. This can sometimes cause a strange odour, but that is normal.

Will the dressing need to be changed before the ten to fourteen day period?

There are times when donor area dressings do need to be changed, such as if the dressing becomes very loose or if there is an excessive loss of fluid through the dressing. This can be done by the hospital nurse if you are still a patient or by your local practice nurse if you have been discharged home.

If the dressing gets loose wet or dirty reapply the outer layers/ contact the practice nurse but do not touch or interfere with the wound. Ensure your wound is kept covered until it is fully healed.

Will I get any pain from the donor site?

Some people experience more pain than others, usually within the first 48 hours. Regular painkillers, such as paracetamol can be taken.

Who will remove the dressing when it is due to be taken off?

On discharge you will be followed up in our adult burns clinic if you still have burns dressings in place. If you are unable to attend our acute burns clinic then the ward staff will arrange either the district nurse or practice nurse to change your dressings. We maintain close links with the community team.

The dressing usually loosens itself as the wound heals. Otherwise it can be soaked off in the bath or shower. If the area is fully healed and dry, then it can be left exposed, and you can massage in moisturising cream or simple emollients, twice a day.

Do not apply it to raw areas as this can cause blistering.

Do I have to be careful about the clothing I wear?

Try not to wear articles of clothing that may make you itch or may be too tight. But if you find that some clothes do rub, a protective dry dressing should be worn.

Will my donor site look like normal skin when it’s healed?

You can expect your donor site to change colour. At first it can look bright red, but over several months it will become slightly darker (depending on your skin type) paler or rougher than normal skin i.e. donor sites tend to always be different, albeit very slightly.

Eventually it will blend in, but it may end up slightly paler than your surrounding skin.

Advice should be taken from your doctor about lifting, stretching and returning to work.

Sun screen advice:

It is very important that both the graft and donor sites are protected from the sun as it is new thinner skin without the normal skin protection. It is very important that you apply high factor sun protection cream (for both UVA and UVB) and wears protective clothing over the areas, as the new skin will burn very quickly and blister. If it becomes tanned this can be a permanent tan that can be blotchy. It is important to protect all newly healed areas from sun damage for at least two years.

Pain and itching:

You may still require medicines after discharge from the hospital to help with pain and itching. Medication will be discussed with you prior to your discharge home.

Itching can be a problem for some people. Regular creaming and massage helps. Wearing loose clothes made from natural materials can also help. If your itching will not settle and becomes a problem please speak to the doctor or nurse at the hospital. There are medicines that can help.

Scar management:

Following skin grafts there will be scarring. Once the wounds have healed you will be referred to the scar management team who will treat the scars to produce the best outcome.

Treatments may include:

Creaming and massage, silicone creams and gels and pressure garments. These will be discussed with you when the wounds are healed. If you are worried about the scarring and you have not been seen by the scar management team, please discuss your concerns at your next follow up appointment with any member of the burns team.

Please contact the Adult Burns help line: 0117 414 3100 / 0117 414 3102.

If you are finding it difficult to come to terms with the treatment plan or with the scars then help is available. Please speak to your nurse or surgeon at the hospital who may be able to help with this. It may be that you would benefit from seeing a clinical psychologist.

The Adult Burns Team are here to help, please ask us any questions you may have about the information in this leaflet or any other issue.

References

Management of Grafts and Donor Sites
British Journal of Nursing (1998) 7: 6,324-334

Management of Skin Grafts and Donor Sites
Nursing Times (2007) vol 103 No 43, 52-53

Patient support

Useful patient support web sites are listed below. If you think it would be helpful and if you wish to meet a burns survivor then please do discuss this option with a member of the burns team.

Adult Burns Unit

Burns | North Bristol NHS Trust (nbt.nhs.uk)

Adult Burn Support UK

Adult Burn Support UK – Information, support and advice about burns in the UK

A support resource for adult burn survivors in the UK.

Email: info@adultburnsupportuk.org

Funded by Dan’s Fund for Burns national charity.

Dan’s Fund for Burns

Dans Fund For Burns – Giving burn survivors the help they need

Dan’s Fund for Burns is a national charity offering practical help to burn survivors in the UK. The charity identifies those most in need of help and provides it in a swift and practical way.

Changing Faces

Changing Faces | Visible Difference & Disfigurement Charity

Changing Faces is a charity for people and families who are living with conditions, marks, or scars that affect their appearance.

Online Health Talk

Healthtalk 
Information about skin grafts and pressure garments                                                                                                                                                                                                            

Katie Piper Foundation

www.katiepiperfoundation.org.uk

The Katie Piper Foundation aims to:

• Progress intensive rehabilitation and scar management for burns survivors.
• Provide information on, and access to non-surgical treatments for burns and scars.
• Campaign for consistent clinical care.
• Develop a support network for people living with burns/scars.
• Help people with burns/scars reconnect with their lives and their communities. 

The Lee Spark NF Foundation

Help & Support for Dealing with Necrotising Fasciitis (nfsuk.org.uk)

01254 878 701

To help those whose lives have been affected by necrotising fasciitis and other severe streptococcal infections.

Outlook

Outlook | North Bristol NHS Trust (nbt.nhs.uk)

Psychological support for people with appearance concerns.

The Fire Fighters Charity Helpline

0800 389 8820

Monday-Friday, 09:00 - 17:00.

The Fire Fighters Charity has a wealth of experience in providing helpline services on a wide range of issues, directing to other relevant benefits that might be available to you, or organisations that may be able to provide assistance. 

Skin camouflage

www.skin-camouflage.net 

Bristol Laser Centre | North Bristol NHS Trust (nbt.nhs.uk)

Acid Survivors Trust International (ASTI)

www.acidviolence.org
A registered charity based in the UK operating as a centre of excellence supporting and working hand in hand with Acid Survivors Foundations (ASFs) in Bangladesh, Cambodia, Uganda and Pakistan.

Adult Burns 24 hour helpline

0117 414 3100
0117 414 3102

Adult Burns Clinic (Monday-Saturday)

0117 414 4005

Burns Clinical Psychology appointments through Acute Burns Clinic Coordinator 

(Monday-Friday)

0117 414 4005 

Scar Management Service/Occupational Therapy (Monday-Friday)

(Monday-Friday) 
07525 618 421
SMC@nbt.nhs.uk

Physiotherapy (Monday-Friday)

0117 414 3114 

Outlook: psychological support for people with appearance concerns 

(Monday-Thursday)

0117 414 4888

Oral Surgery (face masks) 

(Monday-Friday) 

0117 340 6675

If your wound has healed on its own without a skin graft within two weeks then it is unlikely that you will develop scarring. The healed area will be red initially and gradually pale over several months. The skin may be dry and require moisturiser initially but you should be able to return to normal activity very quickly and have no long term difficulties.

If the wound takes longer than two weeks or has required a skin graft to the area then the risks of you developing some scarring is higher. For some people this scarring will cause no difficulties but they may develop into hypertrophic scars.

The reason for this is that it is likely to have been a deeper injury to the skin and therefore more of the skin structures are damaged. When the wound heals the connective tissue (collagen/scar tissue) is laid down to heal the wound. In burn wounds the inflammatory action that enables wound healing continues beyond the wound closure and can cause the area to become more irregular forming raised, thickened, sensitive, itchy and red scars. This type of scarring is called hypertrophic and can develop up to 3 months post wound healing.

There are other factors that can lead to higher risks of problem scars / hypertrophic scars after an injury. These include having an infection that causes the wound to deepen and healing to take longer, if the site of the injury is on areas that are more mobile particularly the chest and top of the shoulder. Your skin type and your genetics can also make you more likely to develop hypertrophic scars. There are a range of factors associated with hypertrophic scarring that make it important to treat:

• The appearance of scars can make people self-conscious and avoid returning to their normal activities.
• Scars across joints can cause problems with movement.
• Scars can be painful, tight, and uncomfortable.
• Scars can be very sensitive.
• Scars can be itchy and can lead to scratching and skin breakdown alongside causing difficulties with sleep.
• Scars can be dry and result in cracking or breakdowns in the skin.
• Scars are more sensitive to the sun and chemicals.

Scarring can take up to 2 years and sometimes beyond to mature so treatment may continue for this long.

Unfortunately it is not possible to prevent hypertrophic scarring. It is, however, possible to minimise the effects and improve the appearance through:

• Moisturising. 
• Massage. 
• Wearing a pressure garment. 
• Using silicone gels / sprays and sheets. 
• Carrying out exercises and stretches. 
• Using splints.
• Resuming your normal daily activities as much as you can.

Sometimes you may be referred to the burns doctors to assess for extra scar treatments, these may include:

• Medication.
• Steroid injections.
• Laser treatment.

• If you have dressings on and no surgery, and it is healed within two weeks, you are unlikely to need scar management input. Superficial burns normally heal without scarring.
• If you have dressings on and no surgery, and it is not healed within two weeks, you will need to be monitored at burns clinic as may require scar management.
• If you have had a skin graft, You will require a review from the scar management team as it is likely your burn was deeper, so the chances of scarring are higher.

Scars and skin graft donor sites require regular creaming to prevent the area from drying, cracking, and becoming sore. This can be because the oil glands in your skin that usually provide moisture can be damaged or destroyed during the injury and the surface layer that prevents water loss is damaged.

It is important to use a non-perfumed moisturiser to keep the area soft and supple, and prevent itching. Perfumed creams can react with the newly healed sensitive scars. Your therapist can provide you with some samples of creams if needed. 

Moisturisers should be applied gently in thin layers while the scars are more fragile and should be done 2-3 times a day. It is important to fully cleanse the area each day to avoid build-up of cream and skin irritation.

Once your wound has healed we will advise you to start gentle massage called gliding. Before putting on your moisturiser place your fingers onto the scar and move in gentle circular motions – you are moving your skin not your fingers to prevent friction. Please ask your therapist to demonstrate. Spend a few minutes using this technique then apply your moisturiser. 

As the scar matures you can increase the pressure of the massage to help soften scars. Your therapist will guide you in this process as massaging too firmly initially can make scarring worse.

As discussed previously the new skin which has formed following the injury lacks the moisture needed. Silicone then acts to seal in the moisture and hydrate the scar. Silicone treatment aims over time to flatten, soften and pale your scar, alongside reducing discomfort. Silicone can be in the form of a sheet, liquid, spray or stick and if recommended by your therapist they will discuss with you the most appropriate type for your scar.

Precautions

• Some people find they are sensitive to silicone.
• If you have been given a silicone sheet it is important to build up wearing it daily from 4 hours on the first day of use by an additional 4 hours each day until the required time recommended by your therapist.
• Check your skin frequently for irritation or rashes over this period. Stop using the silicone and discuss further with your therapist if this does happen.
• If you know you have sensitive skin it may be advisable to patch test silicones away from your scar first to make sure your skin does not react.

Initial wearing schedule for silicone sheet

Silicone sheet

• Your sheet should be cut to size to cover the scar. It is self-adhesive but may require further fixation with a bandage or tape.
• You should wash your sheet twice daily with mild non-oily soap, rinse in warm water, allow to dry then reapply. Use two pieces and rotate between them whilst the washed sheet is drying. 
• Before reapplying, cleanse and dry your skin as normal, moisturise and ensure full absorption of the cream. 
• Your sheet should be worn for at least 12 hours a day and where possible up to 23 hours a day. 
• When the sheet begins to deteriorate and cleaning becomes difficult your gel should be replaced (a piece will last between 1-2 months). 
• The ongoing supply of your silicone treatment should be provided by your GP, these are expensive products so please take care of them and use then as advised.

Silicone gels

• Before being applied, your scar should be fully cleaned as normal. 
• Unless otherwise specified by your therapist then these should be applied twice a day once your moisturising cream has absorbed. 
• Silicone gels go a long way and only a thin layer is required for effective treatment, if they take longer than a minute to dry then you have put on too much.

These are elastic garments that can be off-the-shelf or made-to-measure. They are worn over your scar with the aim of achieving scars that are flat, soft, pale, and comfortable. They could be required to be worn up to 2 years post healing.

They work by applying appropriate levels of pressure to the scar which aims to restrict blood flow/reduce the scar inflammation and inhibit the growth of hypertrophic scar tissue by using constant compression to the area.

To achieve the best possible outcome it is important to wear the garment for 23 hours a day, removing it only to wash, apply moisturiser and change garments.

If your occupational therapist has assessed that pressure therapy is an appropriate treatment for you, they will take appropriate measurements and either fit an off-the-shelf product or send the measurements to an external provider who will make a bespoke garment. You may be required to attend a fitting appointment 2-3 weeks after being measured to check the best possible fit is achieved.

Your garment may require further alteration following this appointment but can then be sent to you in the post along with your repeat garments. If it is not your first garment we may measure you again and you will be asked to contact us to inform of us of the correct fit before being issued with your repeat garments.

After this you will be reviewed around every 3 months as the elasticity of your garments will reduce and optimum pressure is not achieved. It is important to attend your appointments to monitor the progress of scarring and fit of your garments in order to achieve the best results.

Your garment does not protect you from the suns UVA and UVB rays so high factor sun protection will need to be applied underneath the garment. It is also important to continue with recommended cream and massage whilst wearing a garment.

Care instruction and precautions

• Your garments are an expensive product so please take good care of your garments and follow the care instructions 
• Please contact your therapist if you notice any abnormal swelling, blueness, abnormal sensations or sore or broken skin.

Care instructions for made-to-measure garments

• Garments can be hand washed using a non-biological product or machine washed on a 30 degree wash cycle. Do not use fabric conditioner.
• Leave garments to air dry, please do not tumble dry as this will damage your garment.

Care instructions for off-the-shelf garments

• Garments can be washed on a 40 degree or lower cycle.
• Garments can be air dried or tumble dried.

Silontex

Your therapist may also recommend Silontex which is a fabric backed silicone gel sheet that is stitched into your pressure garment.

• It is only suitable to be worn on small areas of scarring. 
• It is washed in the same way as your pressure garment. 
• Silontex should not be used on unhealed areas or open wounds.

Scars are extremely sensitive to sunlight and exposure to the sun without sufficient protection will mean scars burn easily and could cause long term damage darkening the scar which could be irreversible. 

We recommend high factor sun cream with both UVA and UVB protection on scarred areas for 2 years post burn injury and also covering them with clothing to increase the protection.

Itching is unfortunately very common after a burn injury and can continue long after the wound has healed. It can be triggered by activity, heat, and manipulation of the scar.

What can I do?

• Apply moisturising cream regularly. 
• Creams can be cooled in the fridge prior to application which should have a soothing effect. 
• Extremes of temperature can make the itching worse particularly heat so avoid very hot baths or showers. 
• Try and cool, rather than scratch the area, use a fan or place a cold towel over the affected area.

If you are still experiencing problems after trying this advice then your therapist can discuss other options and may refer you to one of the burns consultants.

Hypersensitivity is caused by damage to the nerve endings due to injury of the skin. It can be painful and present as tingling, shooting/burning pain or a severe ‘pins and needles’. The nerve endings in the scar continue to send pain signals to the brain after the wound is healed when there is no longer a need to protect the area. 

If possible it is important to continue normal activity and to not be over protective of the sensitive area, you will not be damaging the area. Your therapist will discuss the techniques with you and which are most appropriate in how to manage the hypersensitivity specifically to your current symptoms.

Desensitisation techniques include: 

(Please do not use these techniques until advised by your therapist)

Massage the hypersensitive area with moisturising cream:

• Start massaging the area (using small circular motions) at a point where there is normal sensation. 
• Gradually move up to a point where the discomfort begins and massage that area until the discomfort eases. 
• Then move up to a point where it feels sensitive and repeat the process. 
• Continue until you have reached the most sensitive point. 
• Carry out 3-4 times a day for approximately 10 minutes.

Stimulate the area with various textures:

• Graded textures can be used to stroke the hypersensitive area. Start with soft materials and work up to coarser textures e.g. cotton wool, felt, toweling, rough cloth, Velcro. 
• If your scar is on your hand or foot they can be immersed in a bowl of materials including: cotton wool, kidney beans, lentils, rice, or pasta. 
• Carry out 3-4 times a day for approximately 10 minutes. Make sure you are looking at the area whilst carrying out the treatment.

Sleep is essential for your health and wellbeing, protecting both your physical and mental health. 

Following a burn injury or trauma there may be many reasons why sleep can be affected including disruption to your sleep pattern, anxiety related to the injury, pain and discomfort and taking medications. 

If you are suffering from poor sleep some of the problems it can cause include:

• Increased pain and discomfort. 
• Restlessness, irritability, and changes in your behaviour. 
• Low mood. 
• Anxiety. 
• Lack of energy. 
• Poor motivation.
• Difficulty concentrating. 
• An increased risk of accidents.

If your scars have any of the following symptoms these can also affect the quality of your sleep:

• Tightness or contractures. 
• Pain. 
• Sensitivity. 
• Itch.

The treatments you are having for your scarring will slowly help improve these symptoms but while you are recovering there are other things you can consider to help improve your sleep.

• Try to stick to a regular routine of when you go to bed and when you get up. Doing so will help you to establish a reliable sleep-waking cycle, which is important for restful sleep. 
• Allow yourself time to switch off and unwind. Try engaging in relaxing activities such as reading a book, listening to restful music, or engaging in relaxation. 
• Initially after your injury you may need to nap during the day. If needed, try to keep the length of your nap short (limited to 30 minutes or less) to reduce the impact on your night-time sleep.
• If you find yourself tossing and turning for longer than 20 minutes, get up and try and do something to make yourself sleepy, such as read a book, complete a puzzle, have a milky drink, or try some relaxation. 
• Avoid food and drinks with caffeine in the evening as these act as stimulants and can keep you awake e.g. coffee/tea/some soft drinks/chocolate/some bakery products. 
• Try not to carryout activities such as surfing the web, playing video games just before bed time. The blue light from devices such as phones/tablets/televisions can impact on your ability to sleep by inhibiting the release of melatonin (a hormone that facilitates the onset of sleep). 
• Exercise is an important part of being physically tired and important for your recovery from your injury to aid sleep but do not do rigorous exercise close to your bed time as it can act as a stimulant, reducing your ability to sleep.
• Consider your bedroom environment, keep it free of clutter and it is usually better to keep it relatively cool as over-heating can increase itch in your scars. Using a fan can be helpful.
• If you sleep with a partner and your needs are different consider having separate duvets at different TOG levels. You can buy bedding that helps control your temperature so it is worth shopping around.
• If you have been advised that you need to position your affected limb, additional pillows can help, you may also want to consider a U or V shaped pillow that can add additional support to painful limbs.

Worry relating to your burn injury, symptoms, or unrelated stressors can all impact on your ability to get a good night’s sleep. Worry and anxiety keeps the brain active and activates the body’s stress response. If you find that worry prevents you from falling asleep or keeps you up at night you may wish to:

• Set time aside earlier in the day to write down your current worries and consider how you might tackle these. 
• Create a relaxing bedtime routine. 
• Note down any concerns that arise during the night and review these in the morning. Committing your worries to paper frees the mind to think of other things and reduces the likelihood of ongoing worry and rumination, which keeps the mind active. 
• Engage in calm (diaphragmatic) breathing or meditation. You may wish to consider listening to restful music, relaxation scripts or specific sleep apps such as Calm.

If you are having difficulty with sleep please talk to your therapist or your doctor as there may be other things that can help including medication or support from the burns psychology service.

There are many useful resources online about improving sleep please see some links below:

Sleep Recovery Tips After a Burn Injury | MSKTC

Home - The Sleep Council

Explore mental health

It is not uncommon for people to experience some appearance related concerns after a burn. 

Our skin camouflage service is available for free for those patients who have sustained a burn injury to their face or hands, for all other injury types and areas of the body there is a charge. 

If the appearance of your scar bothers you and you would like to cover it up as much as possible. Your therapist can make a referral to the skin camouflage service where a specialist can trial specific make-up to cover your scar. You may also be to access camouflage through the charity Changing Faces.

A burn injury or a scar does not just affect someone’s skin but can also influence how they think and feel.

Common experiences are feeling low or vulnerable, some can find that the burn incident is going over and over in their minds; they may experience flashbacks, distressing dreams or are avoiding situations which are reminders of the incident.

People cope in different ways but some find that it helps to talk to someone outside your family or friendship group. We have a burn psychologist within the team who can listen to you and provide support and possible management strategies as part of your rehabilitation. There is also a support service called Outlook which offers psychological support for people with appearance concerns, your therapist can discuss referral to them with you if required.

Once your wounds are fully healed you should be able to bath or shower as previously using your usual washing products. You may also be ready to return to work and start doing any sports or hobbies you did previously. 

You may need a graded return back to work due to reduced range of movement or stamina and are likely to require rest periods during the day dependent on the type of work you do. Please discuss this with your therapist or burns doctor if you require any advice.

Scar appointments at Southmead Hospital are held in Gate 24.

If you have an appointment booked that you can no longer attend or are unsure whether you need the appointment thathas been booked for you then please contact us to let us know. We also provide virtual appointments which can be completed via video call, we will discuss with you if this may be appropriate based upon your scarring and treatment provision.

Adult Burns Unit

Burns | North Bristol NHS Trust (nbt.nhs.uk)

Adult Burn Support UK

Adult Burn Support UK – Information, support and advice about burns in the UK

A support resource for adult burn survivors in the UK.

Email: info@adultburnsupportuk.org

Funded by Dan’s Fund for Burns national charity.

Dan’s Fund for Burns

Dans Fund For Burns – Giving burn survivors the help they need

Dan’s Fund for Burns is a national charity offering practical help to burn survivors in the UK. The charity identifies those most in need of help and provides it in a swift and practical way.

Changing Faces

Changing Faces | Visible Difference & Disfigurement Charity

Changing Faces is a charity for people and families who are living with conditions, marks, or scars that affect their appearance.

Katie Piper Foundation

www.katiepiperfoundation.org.uk

Offers a range of support, rehabilitation and scar management for burns survivors.

Outlook

Outlook | North Bristol NHS Trust (nbt.nhs.uk)

Psychological support for people with appearance concerns.

Talkscar 

A community sharing experiences and knowledge to make life with scars easier. 

talkscars (talkhealthpartnership.com)

Pressure garment manufacturers

Medigarments 

Medigarments Ltd – Designed Around You - Compression garments (jobskin.co.uk)

Juzo 

Juzo · Freedom in Motion

Medi (Duomed) 

Welcome to medi - I feel better. (mediuk.co.uk)

Lipoelastic 

lipoelastic.co.uk

Silicone sheet manufacturers

Cica-Care 

Products (smith-nephew.com)

Molnlycke (Mepiform) 

A world-leading provider of single-use surgical and wound care products | Mölnlycke (molnlycke.co.uk)

Silicone gel manufacturers

Scarsil 

ScarSil® Topical Gel. Scarsil gel – 15ml and 30ml (jobskin.co.uk)

Kelacote – Silicone Spray

Home - Alliance Kelo Cote

Nourisil 

Nourisil™ MD | Scar Gel | Scar Cream | Scar Removal (nourisilmd.co.uk)

Some examples of non-perfumed creams available (there are many others)

Alhydran 

Available through your GP or online purchase. 
ALHYDRAN CO UK 

Aveeno

Available through your local pharmacist, Boots or Superdrug. 
Buy Best Skin Care Products Online - AVEENO

Epaderm 

Available through your GP or Boots. 
Epaderm | Mölnlycke

QV 

Available through your GP or on Amazon. 
Products For Sensitive Skin | QV Skincare United Kingdom

Dermol and Doublebase 

Available through your GP. 
Dry Skin from Doublebase – clinically proven moisturising emollient (mydoublebase.co.uk)

CeraVe 

Available through your local pharmacist, Boots or Superdrug. 
Welcome to CeraVe: Your Skincare Expert | CeraVe

We would really appreciate your feedback about the service we have provided to help with your scarring. Once you have been discharged from our service you can access a short survey to provide your views and it will take no longer than 4 minutes.

Scar Management Feedback Form (office.com)

• Every individual has their own specific dressing requirements. Check with your nurse if you are unsure of yours.
• You will likely go home from hospital with dressings on and your care will be taken over by your practice/district nurse for further dressing changes.
• Your transfer into care of the practice/district nurse will be done by the ward nursing staff on the day of your discharge. You will be given a small supply of dressings and a letter to take with you.
• Normally your dressings need to be changed every 2-3 days, but this will depend on your needs and you will be guided by your nurse.
• If your burn requires a skin graft you will have a donor site. These areas usually take 10-14 days to heal, and if possible the dressing stays in place for this time.
• Keep all dressings dry and clean to help prevent infection.

• When you have been discharged home you may be unable to bath or shower until you are fully healed. When you are healed and no longer have any dressings you should clean your skin every day.
• Your skin might be more sensitive to temperature or can be numb in places. Always test the water temperature with an area of undamaged skin before showering/bathing.
• Use non-perfumed, hypoallergenic soap and cleansing products to prevent skin irritation.

Skin grafts, donor sites, and scars all require regular moisturising to prevent the area from drying, cracking, and becoming sore. This is because newly healed skin is unable to lubricate itself in the same way as undamaged skin. 

• At first moisturising creams or simple emollients should be applied gently. Gradually increase pressure until you can massage the skin.
• Moisturise 2-3 times a day. Occasionally this may be needed more often if your skin is particularly dry.
• It is very important to wash the skin free of cream each day as the build-up of too much can cause irritation.
• Massage involves using firm pressure in circular movements over the scars. Early massage should be gentle, avoiding friction.
• Moisturising creams normally used include E45 or similar oily, non-perfumed emollient creams. There is no good evidence that expensive creams help more than simple emollients.

Itching can be a major problem for some burn patients. Regularly using cool moisturising cream and massage can help. Wearing clothes made of natural fibres can also help. If you have any discomfort and your itching does not settle, then please discuss this with a member of the burns team. There are medications that can help. 

• When you leave hospital it is normal to still need medication to control pain, sensitivity, and itching.
• All your medications will be explained to you.
• If you have any questions, please discuss these with your nurse as soon as possible as alterations to medication can take time to organise.
• You will be discharged home with a small supply of your current medication. Any further prescriptions must be organised with your GP.

The following medications may be given to help control pain at home: 

• Paracetamol - for pain.
• Tramadol or codeine phosphate - for pain.
• Ibuprofen or diclofenac - for pain and inflammation.
• Gabapentin - for itching/nerve pain.

If you need further advice about medications after you have been discharged from hospital you should contact our GP or your team. 

A burn injury doesn’t just affect someone’s skin, it can also influence how they think and feel. People cope in different ways and their reactions differ, but we know that leaving hospital or when treatment ends can be particularly difficult. 

Common experiences include feeling low and vulnerable, while adjusting to changes in your situation or feeling stunned by the whole experience. Some people find the burn incident going over and over in their mind, may experience flashbacks, or distressing dreams. They may also avoid situations which are reminders of the incident or feeling more anxious. Emotions can go up and down in surprising ways without reason. These reactions don’t happen to everyone but are normal after a major event.

If you are finding any of these things difficult, please speak to your GP or contact us. Asking for help is not a sign of weakness - people manage these events in their own way, but sometimes need extra help like any other part of rehabilitation. Staff will listen and support, and we also have a psychologist on the team who you may have met as an inpatient.

Intimate relationships 

People can find that intimate/sexual relationships sometimes change after a burn injury. This can be due to a range of things including fatigue (feeling too tired), distress (feeling low or anxious), worries about appearance, or practical difficulties with the location of the burn/donor sites. These issues usually resolve with time.

It can be difficult to talk about these issues but please speak your GP or a member of staff here as we can offer help. There is also useful information on the Changing Faces website: Changing Faces | Visible Difference & Disfigurement Charity.

Appearance concerns 

Burns can lead to scarring including changes in colour, shape, and texture of your skin These changes may be very visible or not. Either way, it is common to have some concerns about your appearance, including feeling more self-conscious. 

Some people feel less confident in social situations than before, especially being around people they don’t know, and can sometimes find it hard to deal with other peoples’ questions and comments.

If you are finding these sorts of things difficult please let us know as we can provide help. The scar management team are very experienced and you can speak to the burns psychologist. We also work closely with Outlook - a specialist psychology service to help people with concerns about appearance. If you would like an appointment please speak to the burns team or your GP. Changing Faces website also has some information you may find helpful: Changing Faces | Visible Difference & Disfigurement Charity.

After a serious burn injury you are likely to have scarring. The severity of scarring depends on many different factors.

When burns heal there is a risk of developing hypertrophic scars which are red, raised, hard, sometimes sensitive, and often itchy. Once fully healed, treatment for scarring can being and commonly include:

• Moisturising and massage.
• Silicone creams.
• Silicone dressings.
• Pressure garments (made-to-measure Lycra® garments which are worn most of the time).
• Face masks (solid, clear, plastic pressure mask).
• Laser treatment.

Scarring can take up to 2 years to fully settle and some people will need treatment for this time. 

Once you have healed and no longer need dressings you may be referred to the scar management team who will advise you about treatment. If you are worried about scarring and haven’t been referred, please speak to your doctor.

If we cannot see you face-to-face, we can offer video and phone appointments to help reduce travel to the service.

During your stay on the ward you might see a physiotherapist and occupational therapist to help you regain and maintain your normal movement and function.

If you have been given an exercise plan and a splint, you will likely need to continue this when you are discharged home. This is very important to help prevent problems when returning to your normal activities. You should be given advice about this and may be referred for further treatment nearer to where you live. If you have any questions about your specific plan, please ask your therapist for further information.

When you first go home, you may have difficulty doing your everyday activities like cooking and cleaning. In many cases family and friends can support you until you regain independence but this isn’t possible for everyone. If you think you might have difficulties returning home without help, speak to your nurse as soon as possible. Services can take time to arrange and there are criteria for support.

If you need support with ongoing rehabilitation you may be referred to a local community team to provide help when you go home. Sometimes you will need to transfer to a hospital nearer to where you live so your local services can assess your support needs.

Following a burn injury it is recommended you fully protect yourself from the sun for 2 summers, or 2 years. Your new skin including skin grafts and donor sites will blister and burn more easily. To do this keep covered with clothing or using and regularly applying very high sun protection cream (for both UVA and UVB). If you work outdoors you are advised to wear sun protective garments and sun cream.

After this time you should continue using sun protection creams as normally recommended to prevent your skin burning.

The hospital only provides transport home in exceptional cases. It is important you arrange to get home from hospital with family, friends, or public transport. 

When you leave hospital you will be given follow-up appointments to come back and see your doctor. This will be in the Acute Burns Clinic (ABC), next to the Adult Burns Unit (Gate 33a, level 2) or Burns Outpatients (Gate 24 Plastics Outpatient Clinic, level 1). Please ask a nurse if you need a map. You may be seen occasionally for several years after the injury. 

Getting to and from follow-up appointments

Patients can claim back travel costs and car parking at the time of travel if you get any of these benefits: 

• Income Support.
• Income Based Employment and Support Allowance.
• Working Tax Credit or Family Tax Credit.
• Job Seekers Allowance.
• Pension Credit - guaranteed credit.
• H2 form (NHS Tax Exemption Certificate).

Patients must show either a current order book or certificate of entitlement issued no more than 3 months before the appointment. The cashier’s office is in the atrium of the Brunel building and is open Monday to Friday, 10:00 - 12:00, and 13:00 to 15:00. Hospital transport is only provided in exceptional circumstances for medical reasons. 

Work

You may be unable to return to work at first because of open wounds, pain, or tiredness. Please ask your doctor if you need a ‘fit note’ for your employer.

It is important to return to normal activities as soon as possible. This is beneficial to your physical and psychological recovery. At first you could do different tasks, reduce hours, or have a gradual return. Please speak to your doctor or a member of the burns team for advice about returning to work.

Leisure activities

An early return to your leisure activities will give you confidence. However you should not return to contact sports until your wounds have healed. If you wish to swim, your wounds need to be healed due to the risk of infection. Once swimming is recommended, you may find the chlorine irritates your skin. To help with this you can shower and re-apply moisturising cream afterwards. 

Driving

There is no standard time before it is safe for you to drive again. You need to have strength, range of movement, and be free from pain to make sure you are safe to control your car. You need to be able to perform an emergency stop. We can offer guidance about this, but you must discuss your injury with your insurance company before driving. 

• Once home, remember to take pain relief before having a dressing change or doing physiotherapy.
• Eat a healthy balanced diet to help promote healing.
• You are advised to stop smoking as this can affect healing.
• You are likely to be very tired and lack stamina when you first go home, so plan regular rest periods into your day.
• To prevent long-term stiffness, keep the injured area moving.

Use the list below to make sure you have the necessary information and appointments before you go home: 

• Medication.
• Dressings.
• District nurse/practice nurse letter.
• GP letter.

You may have these appointments: 

• Appointment with a practice or district nurse.
• Acute Burns Clinic follow-up appointment.
• Burns Outpatient Clinic appointment.
• Physiotherapy.
• Occupational therapy.

If you are unable to keep any appointments or need further information, contact the Adult Burns Helpline on  0117 414 3100 or 0117 414 3102.

To change or cancel your Plastics Outpatient appointment please phone 0300 555 0103.

If you have been an inpatient on the burns unit you will have the opportunity to complete an online questionnaire about your burns injury outcome within 3 months of discharge. This will be sent to your email address.

Once you have been discharged from the Adult Burns Unit it can be helpful to take painkillers at least 20 minutes before dressing change appointments to help with any discomfort.

Please keep all dressings clean and dry.

If any of the following happen please contact the Adult Burns Unit for advice:

• If you have a high temperature (with or without uncontrollable shaking), a skin rash, or vomiting or diarrhoea. 
• If your dressing becomes wet, dirty, smelly, dislodged (out of place), the wound is exposed or the wound leaks fluid through the dressing. 
• If your wound is not covered by a dressing and becomes red, inflamed, painful, wet, or bleeding. 
   

Skin is especially important and is a protective barrier to the organs in the body: it prevents infection and water loss. When skin is damaged by a burn/scald the protection is lost. If the burn is deeper than the top layer of skin, a skin graft may be required. The burns team will explain and discuss your surgical and wound management options.

Further information on skin grafts and donor sites can be found in our skin graft and donor site leaflet. Ask a member or staff or visit Skin Grafts and Donor Sites Following a Burn Injury | North Bristol NHS Trust (nbt.nhs.uk)

Adult Burns Unit

Burns | North Bristol NHS Trust (nbt.nhs.uk)

Adult Burn Support UK

Adult Burn Support UK – Information, support and advice about burns in the UK

A support resource for adult burn survivors in the UK.

Email: info@adultburnsupportuk.org

Funded by Dan’s Fund for Burns national charity.

Dan’s Fund for Burns

Dans Fund For Burns – Giving burn survivors the help they need

Dan’s Fund for Burns is a national charity offering practical help to burn survivors in the UK. The charity identifies those most in need of help and provides it in a swift and practical way.

Changing Faces

Changing Faces | Visible Difference & Disfigurement Charity

Changing Faces is a charity for people and families who are living with conditions, marks, or scars that affect their appearance.

Katie Piper Foundation

www.katiepiperfoundation.org.uk

The Katie Piper Foundation aims to:

• Progress intensive rehabilitation and scar management for burns survivors.
• Provide information on, and access to non-surgical treatments for burns and scars.
• Campaign for consistent clinical care.
• Develop a support network for people living with burns/scars.
• Help people with burns/scars reconnect with their lives and their communities. 

The Lee Spark NF Foundation

Help & Support for Dealing with Necrotising Fasciitis (nfsuk.org.uk)

01254 878 701

To help those whose lives have been affected by necrotising fasciitis and other severe streptococcal infections.

Outlook

Outlook | North Bristol NHS Trust (nbt.nhs.uk)

Psychological support for people with appearance concerns.

The Fire Fighters Charity Helpline

0800 389 8820

Monday-Friday, 09:00 - 17:00.

The Fire Fighters Charity has a wealth of experience in providing helpline services on a wide range of issues, directing to other relevant benefits that might be available to you, or organisations that may be able to provide assistance.

Skin camouflage

www.skin-camouflage.net 

Bristol Laser Centre | North Bristol NHS Trust (nbt.nhs.uk)

Acid Survivors Trust International (ASTI)

A.S.T.i | Homepage (asti.org.uk)

A registered charity based in the UK operating as a centre of excellence supporting and working hand in hand with Acid Survivors Foundations (ASFs) in Bangladesh, Cambodia, Uganda, and Pakistan.

Burns prevention

Avon Fire & Rescue:

www.avonfire.gov.uk (accessed 10/09/2024).

Please see additional leaflets: 

• Fire safety outdoors.
• Fire safety in the home.

Adult Burns 24 hour helpline

0117 414 3100
0117 414 3102

Adult Burns Clinic (Monday-Saturday)

0117 414 4005

Burns Clinical Psychology appointments through Acute Burns Clinic Coordinator 

(Monday-Friday)

0117 414 4005 

Scar Management Service/Occupational Therapy (Monday-Friday)

(Monday-Friday) 
07525 618 421
SMC@nbt.nhs.uk

Physiotherapy (Monday-Friday)

0117 414 3114 

Outlook: psychological support for people with appearance concerns 

(Monday-Thursday)

0117 414 4888

Oral Surgery (face masks) 

(Monday-Friday) 

0117 340 6675

Before your surgery at North Bristol Trust, you need to complete an online health questionnaire. 

Please go to Synopsis Home to complete your questionnaire. 

You can ask a family member or friend to help you if you have trouble accessing the internet. If you cannot complete the questionnaire at home, you should come to the pre-operative clinic 15 minutes before your appointment time so you can complete it there.

What you need ready before you start:

• Your height and weight.
• Any dates for previous operations (if applicable).
• A list of your current medications (if applicable).
• Your NHS number or hospital number.

When you have answered all the questions, click the share button.

When sharing with the hospital, you will need to: 

• Begin to type North Bristol NHS Trust in the Hospital Box.
• You will need your North Bristol Hospital number which is usually at the top of your appointment letter.
• When you have completed the form please click the green agree and share button. 

Here are some things you can do to help prepare yourself for your operation. For further information visit:

Fitter Better Sooner – general information | The Royal College of Anaesthetists (rcoa.ac.uk)

• Stop smoking: This reduces the risk of breathing problems and makes anaesthetic safer.
• Have paracetamol and ibuprofen ready at home: For pain relief when you are discharged (if you are able to take them).
• Lose weight if you are overweight: This reduces many of the risks of having an anaesthetic and surgery.
• Speak to your dentist: If you have any loose teeth or crowns, treatment from your dentist may reduce the risks of damage to your teeth from equipment used during anaesthesia.
• Speak to us: If you are pregnant or breastfeeding so we can make an appropriate plan for your surgery.
• Speak to your GP: If you have any long-standing medical problems such as diabetes, asthma or bronchitis, thyroid problems, heart problems, or high blood pressure (hypertension) you should ask your GP if you need a check-up, and bring any test results with you.
• Know your regular medications: You will be advised what medication to continue and what to stop before you come into hospital. You must bring a complete, up to date list of your medication with you to all hospital appointments and on admission (a printed prescription or letter from your GP).

If you feel unwell (including fever, productive cough, diarrhoea, vomiting, or a skin infection over the proposed site of surgery) during the 72 hours before you are due to come into hospital, please phone us on 0117 414 0637. 

We may phone you in the week before your surgery to check that you still want to have your operation on the planned date and that there have been no changes in your general health since your preoperative assessment.

• A warm dressing gown and slippers with a non-slip sole.
• Day clothes and underwear.
• A list of any medications you are currently taking.
• Please bring all your belongings in a bag which is no bigger than 40cm high by 25cm wide and 85cm deep, so that it will fit in a patient locker whilst you are having your operation.

Valuables

You are strongly advised not to bring valuables into the hospital.

The Trust can offer limited safe keeping of valuables until arrangements can be made for them to be taken home or until they are returned to you on discharge. A written record will be made of the items to be held in storage and then the items will be stored in a sealed security bag and put into a locked unit. The valuables can be accessed during your stay only in an emergency.

We cannot accept responsibility or liability for cash, valuables or personal property brought into the premises unless they are handed in for safe keeping under circumstances as specified within Trust policy.

What is MRSA?

MRSA is a common bacteria which has developed resistance to methicillin (a type of penicillin), and some other antibiotics that are used to treat infections. 

MRSA is carried harmlessly on the skin and in the noses of many people, without causing an infection. However in hospital, particularly in patients undergoing invasive procedures, it can cause serious infections and can spread easily from one person to another by touch, via hands. Screening for MRSA

Who is screened for MRSA?

• Patients who are going to have certain procedures.
• Other high risk patients including those previously found to have MRSA. 

Swabs are taken from several areas of the body including the nose, any wounds, and urine if a catheter is in place. 

This will not hurt and takes only a few minutes. If you are coming into hospital for an operation this will be done before your operation or procedure.

• If you are found to be carrying MRSA you will be contacted and given treatment.
• If MRSA is not found you will not be contacted.

Treatment 

Treatment is an antibacterial liquid soap for washing skin and hair, and an ointment for application inside the nose.

This treatment can be done at home.

It must be started 5 full days before admission. If your surgery is delayed you will be contacted with further advice.

If you develop an MRSA infection whilst you are in hospital, you may be given antibiotics through an intravenous line (drip).

You can help yourself and other patients:

• Always wash and dry your hands after visiting the toilet, and before you eat.
• Don’t touch your wound or any device that is in your arm, leg, bladder, or body cavity (e.g. a drip, drain or catheter).
• Don’t expose your wound to show your visitors.
• Keep the space around your bed tidy and uncluttered so that the cleaning staff can clean all surfaces easily.
• Tell your nurse if you notice any unclean or dusty areas.
• Shower/wash daily if you can.
• Ask your visitors not to come in large groups, or visit if you are unwell.
• Ask visitors not to sit on your bed or use the patient toilets. n Do not share your possessions or equipment with other patients unless they are cleaned between uses.
• Remind staff about hand washing and drying if they forget – they won’t be offended.

For most patients and hospital staff MRSA poses no threat to their health.

Do

• Do have a bath or shower. This will clean your clean your skin and reduce the risk of infection.
• Do wash your hair. If you are having an operation on your head or neck.
• Do remove nail varnish.
• Do remove jewellery. If you cannot remove your jewellery, it will be covered with tape to prevent damage to the jewellery or to your skin.
• Do wear warm clothing.
• Do take your medications. Unless you have been advised otherwise, and bring your medications with you in their original labelled containers.
• Do leave plenty of time to get to your appointment.

Don't 

• Don’t smoke. This will help avoid breathing problems during your anaesthetic.
• Don’t shave anywhere near the site of surgery.
• Don’t wear make-up or body lotions. This makes sure any heart monitor pads, and dressings can stick to your skin.

Nothing to eat or drink (fasting/‘nil by mouth’). 

It is important you follow these instructions because if there is food or liquid in your stomach during your anaesthetic it could come up to the back of your throat and damage your lungs.

At the appropriate time you will be taken into a mediroom to prepare for surgery:

• You will change into a hospital gown (and your own dressing gown) and a pair of elastic stockings (TEDS). You will be asked to remove any contact lenses. You can keep your pants on as long as they won’t get in the way of the operation.
• Anaesthetists are doctors with specialist training who assess your health and are responsible for giving your anaesthetic and maintaining your safety throughout your surgery.
• You may be visited by the anaesthetist and surgeon to confirm your plan for surgery. Nothing will happen to you until you understand and agree. Please ask any questions you have.
• Premedication (‘premed’) are drugs which are given before some anaesthetics to help with pain relief, indigestion, and occasionally relaxation (but only when the benefits of relaxation outweigh the risks of being drowsy after your operation). A needle may be used to start your anaesthetic. If this worries you, please let us know.
• One person is allowed in the mediroom with you before your procedure. We ask that you and your relative/companion are respectful of other patients. The safety and privacy of all our patients is important to us.

When it is time for your operation a member of staff will go with you to the theatre.

• You may be asked to walk to the operating theatre but this will depend on your general health and whether you have had a premedication. If you are walking, you will need your dressing gown and slippers.
• Theatre staff will check your identification bracelet, your name and date of birth and will ask you about other details in your medical records as a final check that you are having the right operation.
• The theatre may look and feel quite different from other hospital departments – more cold and clinical and will be brightly lit. The theatre staff normally wear coloured ‘pyjamas’ and hats (scrubs).
• You will be asked to remove your glasses and dentures. These will be returned to you immediately after your operation.
• The anaesthetist or anaesthetic assistant will then attach machines which measure your heart rate, blood pressure and oxygen levels.

General anaesthetics 

There are two ways of starting a general anaesthetic:

• Anaesthetic drugs are usually injected into a vein through the cannula (tube in your hand).
• Occasionally you can breathe anaesthetic gases and oxygen through a mask, which you may hold if you prefer. 

Once you are unconscious, an anaesthetist stays with you at all times and continues to give you drugs to keep you anaesthetised. As soon as the operation is finished, the drugs will be stopped or reversed so that you wake up.

Regional (spinal, epidural or nerve blocks) and local anaesthetics

A regional anaesthetic or “block” is an injection of local anaesthetic to make part of your body numb. They are a type anaesthesia and pain relief that can be used with, or sometimes instead of, a general anaesthetic. They are used to enhance your recovery by reducing pain and some side effects that can occur with general anaesthesia and other types of pain relief. 

The local anaesthetic is injected very carefully and may be guided by an ultrasound machine or sometimes a nerve stimulator, which you may feel as gentle twitching. Blocks are usually performed with you awake or sedated if you prefer. If you are having a general anaesthetic they may sometimes be performed after you are asleep. The “blocked” area of your body will become warm, heavy and numb and may last several hours – so after surgery you’ll be advised how to protect yourself until normal sensation returns. You’ll also be reminded to take regular painkillers around this time so you remain comfortable when the numbness wears off. 

Regional and local anaesthetic techniques are generally safe and effective although risks may occasionally include an incomplete block, bruising around the injection site, or damage to veins, arteries or nerves. Other serious complications such as seizures or heart problems are rare and your anaesthetic team are trained to deal with these. 

Your anaesthetist will explain everything that is involved in a regional anaesthetic, including how any benefits and risks relate to you and your operation. 

For more information “Nerve Blocks: An Information Video for Patients” can be found at: 
Patient information leaflets and video resources | The Royal College of Anaesthetists (rcoa.ac.uk)

Blood carries oxygen around the body and a lack of red blood cells is called anaemia. In some cases anaemia can be treated with medicines; in others, a blood transfusion may be the best treatment. You can reduce the need for a blood transfusion by eating foods containing iron before your operation.

You may have a blood sample taken in pre-op assessment before your operation to see if you are anaemic. A second sample of blood is required within 7 days of the operation and is often taken on admission.

If you have previously been given a card which states that you need to have blood of a specific type, please show it as soon as possible to your doctor, nurse or midwife and ask them to tell the hospital transfusion laboratory.

Blood transfusion is only needed for a small number of patients during or after surgery. Sometimes it is possible to recycle your own blood during the operation. A blood transfusion is usually given through a tiny tube directly into a vein, and you will be observed before, during, and after.

You do have the right to refuse a blood transfusion, but you need to fully understand the consequences of this. If you have any concerns you should discuss these with your doctor, nurse. or midwife.

• After the operation, you will be taken back to a mediroom. Recovery staff will be with you at all times and will continue to monitor your blood pressure, heart rate and oxygen levels.
• Oxygen will be given through a lightweight clear plastic mask, which covers your mouth and nose. Depending on the operation you have had, you may have a urinary catheter. This is a soft tube put temporarily into the bladder to drain it.
• If you are going home on the same day, once you have had something to drink/eat and are considered “ready for discharge”, you may be taken to a seated recovery area to wait for collection or transport.
• Whilst we make every effort to reunite you with your relative/companion following your procedure the nurses will assess this on an individual basis. Your relatives /companions are welcome to ask at the reception desk about your progress.

Good pain relief is important and some people need more pain relief than others.

If you can breathe deeply and cough easily and you can move around freely after your operation, you are less likely to develop a chest infection or blood clots.

Occasionally, pain is a warning sign that all is not well, so you should ask for help when you feel pain.

Here are some ways of giving pain relief:

• Pills, tablets or liquids to swallow: You will need to be able to eat, drink and not feel sick for these drugs to work. They take at least half an hour to work.
• Injections: These may be given through a needle in your vein or muscle and take up to 30 minutes to work.
• Suppositories: These waxy pellets are put into your back passage (rectum). They are useful if you cannot swallow or if you might vomit.
• Patient controlled analgesia (PCA): This is a method using a machine that allows you to control your pain relief yourself.
• Local anaesthetics and regional blocks.

How you feel afterwards will depend on the procedure and anaesthesia you’ve had - please speak to us if you feel uncomfortable.

Very common (more than 1 in 10)

• Nausea (feeling sick).
• Shivering.
• Thirst.
• Sore throat.
• Bruising.
• Temporary memory loss (mainly in over 60s). 

Common (between 1 in 10 and 1 in 100)

• Pain at the injection site.
• Minor lip or tongue injury.

Uncommon (between 1 in 100 and 1 in 1000)

• Minor nerve injury.

Rare (between 1 in 1000 and 1 in 10,000)

• Permanent peripheral nerve damage (1 in 1000).
• Corneal abrasion (scratch on the eye) (1 in 2800).
• Damage to the teeth that needs treatment (1 in 4500).
• Anaphylaxis/severe allergic reaction (1 in 10,000).

Very rare (between 1 in 10,000 and 10,000 or more) 

• Awareness during anaesthesia (1 in 20,000).
• Loss of vision (1 in 100,000).
• Death as a direct result of anaesthesia (1 in 100,000).

The risks to you will depend on:

• Your age and whether you have any other illness.
• Factors such as smoking or being overweight.
• Surgery which is complicated, long, or done in an emergency. 

For more information about risks visit:

Risk leaflets | The Royal College of Anaesthetists (rcoa.ac.uk)

DVT: Deep Vein Thrombosis

A blood clot that forms in a vein

Pulmonary Embolus

A blood clot that has travelled to the lungs.

Venus Thromboembolism

A term to describe both DVT and PE.

Causes

Sometimes a DVT happens for no apparent reason. Some people inherit or develop an increased risk of DVT. Being unwell and having reduced mobility (for example, when recovering from an operation) can lead to changes in the blood and sluggish blood flow through the leg veins. These events make blood more likely to clot and form a DVT.

The highest risk is associated with major joint operations such as those for joint (hip or knee) replacement or hip fracture, major trauma or major spinal surgery, especially if someone has multiple risk factors for DVT.

Possible symptoms

• Skin warmth.
• Swelling.
• Redness.
• Tenderness.
• Breathing difficulties.
• Chest pain. 

How to reduce the risk

On admission to hospital or at your pre-operative assessment, you will have an assessment of your risk of DVT and any reason not to use preventative treatments. The assessment will decide the recommended preventative measures (known as thromboprophylaxis) to be used in hospital and what is recommended after leaving hospital. 

These may include:

• Avoiding dehydration.
• Getting up and moving early and frequently.
• Use of elastic support (anti-embolic) stockings.
• Injections of heparin (an anticoagulant or “blood thinner”).
• Intermittent compression boots (to gently squeeze the legs) may be recommended.
• Occasionally the use of tablet anticoagulation medication (e.g. warfarin, dabigatran or rivaroxaban).
• Vena Cava Filter (an umbrella shaped device inserted into a large vein to stop blood clots moving towards the lungs).

What happens if a VTE does develop?

An assessment is made by the medical team, and a scan can be done. If the test results are positive, anticoagulation treatment is given to prevent further clot formation and allow the DVT or PE to breakdown.

If you are having an operation and you are taking a drug that thins your blood (e.g. aspirin, warfarin, dabigatran, rivaroxaban, clopidogrel) your healthcare team should assess the risks and benefits of stopping this drug temporarily in the week before your operation with or without different treatment in its place.

For 24 hours after a general anaesthetic

You should:

• Have a responsible adult with you.
• Drink plenty of fluids.
• Take thinks gently including having time off work until you feel fully recovered. 

You should not:

• Make any important legal or financial decisions or sign any such documents.
• Be left alone caring for children.
• Drive.
• Cook, boil a kettle, or operate machinery.
• Drink alcohol or take sleeping tablets. 

If you stay in hospital longer than is necessary you are at far greater risk of losing your independence or developing complications such as infections or DVT. 

• From the day you are admitted to hospital the staff involved in your care will work together with you and your relatives/carers to assess your needs in preparation for leaving hospital.
• On the first day of your stay you will receive an estimated date of discharge (EDD) which may change as your care progresses.
• As part of your treatment it may be necessary for you to move to another ward, sometimes at short notice but you and your relatives/carers will be given as much information as possible.
• Where possible you will be able to vacate your hospital bed by 10am on your day of discharge, but you may need to wait in the hospital discharge lounge until transport arrives.
• Before you leave hospital you will be given a limited supply of any medication that you need and any changes that have been made will be explained to you.
• You will be given a written discharge summary which includes details of your medication and any changes. Please also take a copy of this to your next GP appointment.

Discharge arrangements may include any of the following options

• Returning to where you usually live with no additional support.
• Returning home with either short term or long term support services in place. Please let us know as soon as possible if you already have support services in place.
• Moving to a short term rehabilitation or intermediate care setting as close to your home as possible.
• Moving to alternative housing or care home.

Preparation

When your discharge date is identified you and your relatives/ carers will need to make the necessary arrangements which may include:

• Transport home: Where possible you will be expected to arrange your own transport to arrive by 10am on the day of your discharge.
• Suitable clothing and footwear.
• Access to a key to your property.
• Reinstate any private care arrangements.
• A suitable supply of food, and adequate heating in your home.

Southmead Hospital preadmission unit 0117 414 0637

The Royal College of Anaesthetists 
Churchill House 
35 Red Lion Square 
London 
WC1R 4SG 
Phone: 020 7092 1500 
E-mail: info@rcoa.ac.uk 
Website: Homepage | The Royal College of Anaesthetists (rcoa.ac.uk) 
Patient information and videos available at: For patients | The Royal College of Anaesthetists (rcoa.ac.uk)
The organisation is responsible for keeping up standards in anaesthesia, critical care and pain management throughout the UK.

Association of Anaesthetists of Great Britain and Ireland 
21 Portland Place 
London 
W1B 1PY 
Phone: 020 7631 1650 
E-mail: info@anaesthetists.org 
Website: Home | Association of Anaesthetists
This organisation works to promote the development of anaesthesia and the welfare of anaesthetists and their patients in Great Britain and Ireland.

NHS Constitution. Information on your rights and responsibilities available at: 
NHS Constitution for England - GOV.UK (www.gov.uk)

NHS information on MRSA available at: 
MRSA - NHS (www.nhs.uk)

NICE guidance on venous thromboembolism available at: 
Overview | Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism | Guidance | NICE

1 Information about blood transfusion available at: 
Blood transfusion - NHS (www.nhs.uk)

Researchers assessed whether Delta SARS-CoV-2 infection resulted in worse patient outcomes than Omicron SARS-CoV-2 infection, in hospitalised patients

The study, published in The Lancet Regional Health – Europe, aimed to provide more detailed data on patient outcomes, such as the need for respiratory support.

The research demonstrated that Omicron infection resulted in less serious outcomes than Delta in hospitalised patients. Compared to Delta, Omicron-related SARS-CoV-2 hospitalisations were 58% less likely to need a high level of oxygen support, 67% less likely to need ventilatory support (such as a ventilator) or more critical care, and 16% less likely to have a hospital admission which lasted for more than three days.

Dr Catherine Hyams, Post-Doctoral Clinical Research Fellow, Principal Investigator for the AvonCAP study and one of the study’s lead authors at the University of Bristol, said: "By finding out the reduced requirement of increased oxygen support and total positive pressure support, including non-invasive ventilation, our analysis should contribute to future hospital care and service planning assessments. 

"However, the impact of lower severity Omicron-related hospitalisation must be balanced with increased transmissibility and overall higher numbers of infections with this variant."

The research team suggest there should be ongoing evaluation of the severity of new variants of SARS-CoV-2, along with careful planning of healthcare resource to avoid healthcare systems being overwhelmed.

Dr Leon Danon, Associate Professor in Infectious Disease Modelling and Data Analytics, in the Department of Engineering Mathematics and one of the study's lead authors, added: "These results have been published at a time when China is experiencing a resurgence of COVID-19 and may be useful in helping to understand what is happening there."

This research, published in The Lancet Regional Health – Europe, provides the first estimates of two- or three-dose Pfizer-BioNTech COVID vaccine effectiveness against hospital admission for more than three days and against respiratory difficulty requiring oxygen or ventilatory support.

Many studies have reported the effectiveness of the COVID-19 mRNA vaccines against hospitalisation, but few have assessed the effectiveness against clinically relevant measures of COVID-19 severity. Using detailed clinical data from Bristol’s two acute hospital Trusts, NBT and UHBW, researchers estimate the effectiveness of two- or three-doses of the (original/monovalent) Pfizer-BioNTech vaccine against hospitalisation for infection with either Delta or Omicron SARS-CoV-2 variants.

The study showed that receipt of two-doses of Pfizer-BioNTech vaccine may result in an 83% reduction in the rate of hospitalisation due to Delta SARS-CoV-2 infection, compared to the unvaccinated. Two doses also prevented severe in-hospital outcomes due to Delta SARS-CoV-2 infection, reducing the likelihood of a hospital admission lasting more than three days by 63%.  The researchers also found that two doses of this vaccine reduced the risk of a patient needing increased oxygen or ventilatory support by 52% and 59%, respectively.

Receipt of three-doses of Pfizer-BioNTech vaccine was also found to be effective in reducing Omicron infection severity, compared to the unvaccinated, including in older adults, reducing the risk of hospitalisation for more than three days with Omicron SARS-CoV-2 by 56%, and decreasing the risk of needing high-level oxygen or ventilatory support by 42% and 59%, respectively. This is additional evidence that Pfizer-BioNTech vaccine is effective in reducing hospital admissions due to Delta and Omicron SARS-CoV-2 infection.

Dr Anastasia Chatzilena, Postdoctoral Research Associate in the Department of Engineering Mathematics, and a lead author of the study, said: "Our research has shown the Pfizer-BioNTech vaccine provides effective protection against hospitalisation from Delta and Omicron infection and has significant benefits in terms of preventing severe disease, including critical care admission and respiratory failure.

"However, the benefit provided by vaccination decreases over time which appears to be more pronounced in older adults, so careful ongoing monitoring of vaccine effectiveness and SARS-CoV-2 disease severity for emerging variants remain important."

An increase in the number of non-COVID-19 respiratory infections should be expected this winter, say scientists. The warning comes following the results of a new study, published in The Lancet Regional Health – Europe, which found that over 55% of respiratory disease hospitalisations during the pandemic’s peak were caused by non-SARS-CoV-2 infections.

The study is the first to compare the number of hospitalisations from respiratory disease infections caused by COVID-19 and non-SARS-CoV-2 infections.  

Using data from 135,014 hospitalisations from two large hospitals in Bristol between August 2020 and November 2021, researchers identified 12,557 admissions attributable to acute Lower Respiratory Tract Disease (aLRTD) with patients admitted with signs or symptoms of respiratory infections including cough, fever, pleurisy, or a clinical or radiological aLRTD diagnosis. Of these, 12,248 (98%) patients, comprising mainly older adults, consented to participate in the study.

Following further analysis, the team show that of the 12,248 aLRTD hospitalisations, 55% (6,909) were due to infection with no evidence of SARS-CoV-2, while confirmed SARS-CoV-2 infection only accounted for 26% (3,178) of respiratory infections. The remaining 17% (2,161) were due to infection with no infective cause.